Isaksson S, Schwarz A, Rusner M, et al. J Patient Saf. 2022;18:325-330.
Organizations may employ one or more methods for identifying and examining near misses and preventable adverse events, including structured record review, web-based incident reporting systems, and daily safety briefings. Using each of the three methods, this study identified the number and types of near misses and adverse events. Results indicate that each method identifies different numbers and types of adverse events, suggesting a multi-focal approach to adverse event data collection may more effectively inform organizations.
Alpert AB, Mehringer JE, Orta SJ, et al. J Gen Intern Med. 2022;Epub May 31.
Transgender patients who experience or perceive bias when receiving care may avoid or delay seeking care in the future. In this study, transgender patients reported on their experiences in viewing their electronic health record (EHR). In line with previous studies, transgender patients reported experiencing harms in several ways, such as providers using the wrong pronouns, wrong name, or wrong gender marker. The structure of the EHR (e.g., no separate fields for sex and gender) itself also created barriers to quality care.
Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.
Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review.
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.
Kutza J-O, Hübner U, Holmgren AJ, et al. Stud Health Technol Inform. 2022:885-889.
As use of health information technology (IT) applications expands, experts have raised patient safety concerns. Based on a literature review and expert feedback, this article summarizes approaches for assessing digital patient safety maturity in hospitals in order to maximize both health IT implementation and high quality, safe patient care.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.
Davy A, Borycki EM. Stud Health Technol Inform. 2022;290:438-441.
Dashboards provide a way to display patient safety data (e.g., medication safety) in real time. This narrative review and SWOT (strengths, weaknesses, opportunities, threats) of existing patient safety dashboards can form the basis for developing future dashboards.
Devarajan V, Nadeau NL, Creedon JK, et al. Pediatrics. 2022;149:e2020014696.
Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.
Powell ES, Bond WF, Barker LT, et al. J Patient Saf. 2022;18:302-309.
Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.
Kostick-Quenet KM, Cohen IG, Gerke S, et al. J Law Med Ethics. 2022;50:92-100.
Biases in decision support technologies precipitate racial inequities. This commentary discusses how algorithms in machine learning contribute to inaccuracies in the care of persons of color and the displaced. Legal actions to mitigate racial biases in decision making programs and implementation steps toward improvement are discussed.
Joseph AL, Monkman H, Kushniruk AW, et al. Stud Health Technol Inform. 2022;2022:535-539.
Patient portals allow patients and their caregivers to read clinical notes, view test results, and communicate with their provider, with the goal of improving patient safety. This scoping review found limited evidence of improved patient safety with the use of patient portals. Additionally, the authors found multiple naming conventions, such as patient portal, personal health record, and personal medical record.
Peivandi S, Ahmadian L, Farokhzadian J, et al. BMC Med Inform Decis Mak. 2022;22:96.
Speech recognition software is a potential strategy to reduce documentation burden and burnout. This study compared the accuracy handwritten nursing notes versus online and offline speech recognition software. Findings indicate that the speech recognition software was accurate but created more errors than handwritten notes.
Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;Epub Apr 7.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels.
Iredell B, Mourad H, Nickman NA, et al. Am J Health Syst Pharm. 2022;79:730-735.
The advantages of automation can be safely achieved only when the technologies are implemented into processes that support their proper use in regular and urgent situations. This guideline outlines considerations for the safe use of computerized compounding devices to prepare parenteral nutrition admixtures with the broader application to other IV preparations in mind. Effective policy, training, system variation, and vendor partnerships are elements discussed.
Hautz WE, Kündig MM, Tschanz R, et al. Diagnosis. 2021;9:241-249.
Diagnostic errors can be identified by measuring concordance of initial and final diagnosis, for instance admission and discharge diagnoses. In this study, researchers developed and tested an automated trigger system to determine concordance between pairs of diagnoses. In comparison to the reference standard (concordance determined by experts) the automated system performance was excellent.
Lichtner V, Dowding D. Stud Health Technol Inform. 2022;294:740-744.
Barcode medication administration (BCMA) processes are designed to prevent some types of medication administration errors. This article discusses how BCMA workflows support error prevention and how to identify workarounds that negate these error prevention mechanisms.
Estiri H, Strasser ZH, Rashidian S, et al. J Am Med Inform Assoc. 2022;Epub May 2.
While artificial intelligence (AI) in healthcare may potentially improve some areas of patient care, its overall safety depends, in part, on the algorithms used to train it. One hospital developed four AI models at the start of the COVID-19 pandemic to predict risks such as hospitalization or ICU admission. Researchers found inconsistent instances of model-level bias and recommend a holistic approach to search for unrecognized bias in health AI.
Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.
Rotenstein LS, Melnick ER, Sinsky CA. JAMA. 2022;327:2079-2080.
Clinician well-being is increasingly seen as a quality and safety issue. This commentary discusses how systemic efforts must be built to enhance occupational well-being among clinicians. This approach discussed should consider both human factors and organizational design strategies to reduce burnout, cognitive overload, process frustration, and technology use.
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